The Cardiac Care Center was designed with efficiency in mind and thus was outfitted with state-of-the-art catheterization laboratory equipment. The technology utilized includes Siemens radiography, database management, digital review, and Cathcor documentation equipment. Contrast is administered with the ACIST (angiographic contrast injection system technology) system (Bracco; Milan and Minneapolis). ACIST is an automated contrast and fluid delivery system that gives the physician control over the volume and flow of the contrast material.

In addition, because ACIST eliminates the need for manifolds and multiple syringes and thus simplifies cleanup, the procedure room is more easily and quickly prepared for the next patient.

"Everything was chosen with the patient's safety and optimal operational efficiency in mind," explains Christine Coyne, director of the center. "When the patient arrives for his or her appointment, we already have in hand the medical records, laboratory reports, history, physical examination findings, and signed consent form, so we are ready to get to work. Having the newest technology ensures that the procedure will go smoothly," she says.

"With use of the ACIST, it is possible to use a much smaller catheter, typically a 4-French, and we have been able to reduce the bed-rest time by 50%: from 3 hours down to 90 minutes," Coyne reports. The center has done a follow-up study and has noted no complications associated with the reduced postprocedural resting period, which enhances the work flow. There also is no difference in image quality with use of ACIST with smaller catheters, and the risk of complications with the smaller catheter is lower.

"Because we use the ACIST, we are able to decrease the amount of contrast material injected. The physicians use an average of 90 to 120 cc per diagnostic case, and presently our goal is 100 cc per case," Coyne reports. "This is much safer for the patient, especially if there is a need for an interventional procedure later, at which point contrast will be injected again."

 The center uses Isovue 370®, the highest concentration contrast media available for catheterization laboratory procedures, providing high diagnostic yield. It is available in multiple fill sizes, allowing for flexibility with the workload and daily schedule. For example, early in the day, a 500ml multidose (Isovue Multipack®) bottle can be hung for 4 to 5 patients and and used up to 10 hours. Later in the day, if there is only 1 patient left on the schedule, the technologist can hang a 100cc bottle. So, the use of less contrast material translates into operational savings for the center in addition to increased safety.

Because the Cardiac Care Center was established for diagnostic cardiac catheterizations and operates on an outpatient basis, the patients generally are of a low-risk status. The center wants cardiologists and patients to view it as an extension of the physician's office, offering more efficient work flow than a hospital laboratory and a less intimidating environment, says Coyne.

The clinical protocol begins when the patient arrives and is greeted by a staff member, who checks the patient's identification. The patient is then escorted to one of nine private guest rooms and is assessed by a nurse; this is followed by recording of vital signs, placement of the intravenous line, and preparation of the entry site. The patient's family or significant others are allowed to come back to the patient's room and are present for the precatheterization teaching session.

When the physician is ready to perform the procedure, he or she goes in to greet the patient, who is then taken to the sterile procedure room. The procedure takes about 40 minutes, after which the patient is taken back to the assigned private room and the catheter sheath is removed. Pressure is manually applied to the entry site for approximately 15 to 20 minutes.

When patients are ready to sit up during the recovery period, they are given lunch before getting ready to go home. The nurses always emphasize to the patients how important it is for them to drink lots of fluids within the first 24 hours and at least one liter before they leave the center, in order to flush out the contrast material. As part of the discharge instructions, nurses talk at length with the patients about how to care for the wound at home and what signs of complications to note and report, eg, redness, drainage, swelling, fever, and pain or tingling in the lower extremity.

Seleen Street Collins is a contributing writer for Decisions in Imaging Economics.